Nutr Hosp.

2009;24(4):492-497
ISSN 0212-1611 CODEN NUHOEQ
S.V.R. 318

Original

Viscosity and flow-rate of three high-energy, high-fibre enteral nutrition

formulas
P. Casas-Augustench1 and J. Salas-Salvad1,2
Human Nutrition Unit. Hospital Universitari Sant Joan de Reus. IISPV. Rovira i Virgili University. Reus. Spain. 2CIBER Fisiopatologa de la Obesidad y Nutricin (CB06/03). Instituto de Salud Carlos III (ISCIII). Madrid. Spain.

Abstract
Introduction: There have been few studies evaluating
how the viscosity of the enteral nutrition formulas determine the time of nutritional administration by gravity
and whether viscosity causes tubes to become obstructed.
Objective: To assess how long it takes for three polymeric, hypercaloric and fibre-rich enteral nutrition formulas marketed in Europe to pass through different
nasointestinal tubes by gravity and whether these formulas obstruct the tubes.
Methods: We evaluated the in vitro viscosity of the
three formulas using a rotational viscometer and by calculating how long these formulas took to pass by free fall
through the equipment and different calibre tubes. We
also assessed the possible obstruction of the tubes or the
equipment after the three formulas had been administered, simulating the administration conditions in clinical
practice (1,500 ml over 24 h).
Results: The administration time by gravity of 500 ml
of each of the formulas studied was closely related to the
viscosity determined in vitro of each of the formulas used.
The larger the internal diameter of the tube, the shorter
the emptying time by gravity or free fall. The possibility
of tube obstruction was higher in the case of the two more
viscous formulas.
Conclusions: The viscosity of the enteral nutrition formulas should be included in the labelling of the product.
This information would assist the clinician to make decisions about the kind of formula to be used with different
types and calibres of tube.

(Nutr Hosp. 2009;24:492-497)

Key words: Enteral nutrition. Nasoenteric tube. Viscosity.
Time of administration.

VISCOSIDAD Y FLUJO DE CADA LIBRE

DE TRES FRMULAS DE NUTRICIN ENTERAL
RICAS EN ENERGA Y FIBRA
Resumen
Introduccin: Existen escasos estudios que evalen el
efecto de la viscosidad de las frmulas de nutricin enteral sobre el tiempo de administracin de la nutricin por
cada libre y la posibilidad de obturacin de la sonda utilizada.
Objetivos: Evaluar la presencia de obturacin y tiempo
de paso de tres frmulas polimricas hipercalricas y
ricas en fibra de nutricin enteral a travs de diferentes
sondas nasointestinales por gravedad.
Mtodos: Se evalu la viscosidad in vitro de tres frmulas mediante un viscosmetro rotacional y el tiempo por
cada libre a travs de un equipo y sondas de diferente
calibre de tres frmulas ricas en fibra comercializadas en
Europa. Tambin se evalu la presencia de obturaciones
de la sonda o el equipo tras la administracin de las tres
frmulas simulando las condiciones de administracin en
la prctica clnica (paso de 1.500 ml durante 24 h).
Resultados: El tiempo de administracin por gravedad
de 500 ml de cada una de las frmulas se relacion estrechamente con la viscosidad determinada in vitro de cada
una de las frmulas utilizadas. A mayor dimetro interno
de la sonda, menor fue el tiempo de vaciado por cada libre
o gravedad. La posibilidad de obturacin de la sonda fue
mayor en el caso de las dos frmulas ms viscosas.
Conclusin: La viscosidad de las frmulas de nutricin
enteral debera figurar en el etiquetaje del producto. Esta
informacin ayudara al clnico a tomar decisiones sobre
el tipo de frmula a emplear en funcin del tipo y calibre
de sonda a utilizar.

(Nutr Hosp. 2009;24:492-497)

Correspondence: Jordi Salas-Salvad.
Human Nutrition Unit.
Department of Biochemistry and Biotechnology.
Faculty of Medicine and Health Sciences.
University Rovira i Virgili.
C/ Sant Lloren, 21.
43201 Reus.
E-mail: jordi.salas@urv.cat
Recibido: 11-VIII-2008.
Aceptado: 2-IX-2008.

492

Palabras clave: Nutricin enteral. Sonda nasogstrica. Viscosidad. Tiempo de administracin.

Introduction
The development and deployment of artificial nutrition techniques has brought about the possibility of
increasing life expectancy in different situations and diseases. The use of enteral nutrition has grown in recent
years.1-3 This is partly because the parenteral support that
often was used in some situations has not shown to be
advantageous compared to the enteral feeding technique.
Enteral nutrition through nasogastric or nasointestinal tubes is the most commonly used technique in artificial nutritional support both in hospitals and outpatients. The method of tube administration most
frequently used in chronic patients is intermittent or
continuous by gravity. However, in acute care hospitals, continuous administration through a pump is also
widely used in different situations requiring continuous input of small quantities of nutrients over time.
This promotes the proper use of nutrients and reduces
the risks associated with the slowdown of the normal
gastrointestinal transit.
Tube obstruction is a relatively common complication that can be seen both in the hospital and at home.
Obstruction stops the administration of nutrients and
sometimes medication and this has consequences for
the individual. In addition, the obstructed tube often
has to be replaced by another tube, which means added
inconvenience and risks for the patient.4,5
On many occasions, the passage of nutrients through
the tube also slows down because of the viscosity of the
formula administered and/or the small size of the tube
used.6,7 This may mean the nutrients are inadequately
administered and thus can lead to negative consequences and inconvenience for both caregiver health
personnel and family members or patients themselves.

It has been previously seen that using highly viscous

hypercaloric formulas may lead to an increased risk of
obstructing tubes as well as a delay in administration.
However, there are few studies that evaluate the effect
of the type of formula and tube on the time required to
administer enteral nutrition by gravity and the possibility of tube obstruction1.
Therefore, the purpose of this study is to assess three
high-energy, high-fibre enteral nutrition formulas for
their viscosity, their falling time using gravity and their
likelihood of causing obstruction in nasoenteric tubes
of different calibres.
Material and methods
This study was divided into three phases: a) in vitro
viscosity determination of three hypercaloric and rich
in fibre enteral nutrition formulas; b) comparison of the
time needed to pass 500 ml of the three enteral nutrition
formulas using different calibre nasoenteric tubes by
free fall; and c) assessment of the possibility of tube
obstruction after administration by gravity of 1,500 ml
of the three enteral nutrition formulas for 24 hours.
Enteral nutrition formulas and tubes used
We compared three hypercaloric enteral nutrition
formulas (between 1.5 and 1.6 kcal/ml) enriched in
fibre and marketed in Europe; table I shows their composition. Two of the three formulas with similar caloric
content had the same energy density (Nutrison Energy
Multi Fibre and Jevity Hi Cal). Both the quantity and
the type of fibre (soluble/insoluble relationship) were

Table I
Nutritional composition of the enteral nutrition formulas
Isource Energy
Fibre*
Energy (kcal)

Nutrison Energy
Multi Fibre#

160

Proteins (g)
Carbohydrates (g)

150

Jevity Hi Cal#
150

6.0

6.0

6.4

20.0

18.5

20.1

Lipids (g)

6.2

5.8

4.9

Fibre (g)

1.5

1.5

1.2

50% soluble
50% insoluble
Inulin
Polysaccharide soybeans
Fibre oats

47% soluble
53% insoluble
Polysaccharide soybeans
Cellulose
Fibre acacia (Arabic gum)
Inulin
Oligofructose
Resistant starch

75% insoluble
25% soluble
Fibre oats
Polysaccharide soybeans
Arabic gum
Carboxymethyl cellulose

Type of fibre

Osmorality (mOsm/L)

347

335

397

Nutritional content per 100 ml of enteral nutrition formula.

*Data provided by the laboratory. #Data provided by vademecum 2008 for each laboratory.

Viscosity and flow-rate of three enteral

nutrition formulas

Nutr Hosp. 2009;24(4):492-497

493

Table II
Characteristics of tubes tested
French
size

Length
(cm)

Internal diameter
(mm)

External diameter
(mm)

Radiopaque polyurethane

120

1.8

2.6

Radiopaque polyurethane

9/18

150

3.0/2.2

6.0/4.8

Radiopaque polyurethane

10

120

2.5

3.3

Radiopaque polyurethane

12

120

3.0

3.96

Type of tube

very similar in the case of the formula Isosource

Energy Fibre and Nutrison Energy Multi Fibre.
Three polyurethane nasogastric tubes with different
calibre (Compat 8, 10 and 12 French, Nestle Healthcare Nutrition, SA) and one nasojejunal tube (Compat
Stay-Put 9/18 French, Nestle Healthcare Nutrition,
SA) were used for evaluating the infusion time and the
possibility of obstruction. Table II shows the characteristics of each of the tubes used.
Viscosity assessment
The viscosity of the enteral nutrition formulas was
determined in triplicate in vitro through a rotational viscometer Brookfield (Brookfield Engineering, Stoughton,
MA) at 25 C. The average of the three determinations
was the accepted value.

infusion was graduated at a velocity of 1-drop/3 seconds (1 drop is equivalent to 20 L). The administration of the formula was timed from the beginning to
finish. The presence or absence of obstructions was
recorded and, if appropriate, the time at which the stoppage occurred. The amount of formula that remained in
the bag after the end of the administration was also
weighed. With this test, we attempted to simulate as
closely as possible the normal clinical conditions of
tube administered enteral nutrition (administration of
1,500 ml in 24 hours).
The experiment was conducted at room temperature
of 25 C and was repeated three times for each formula
using the tube (9/18FR). For this experiment, nasojejunal tube (9/18) was used since this is the tube in which
obstructions are most frequently observed in clinical
practice, particularly with products rich in fibre.
Statistical methods

Fluidity determination by free fall

Results are shown as means and standard deviations.
The fluidity of the formulas was estimated by
observing the time of administration by free fall of each
of the formulas. After the formula had been shaken
(500 ml) for 30 seconds, it was hung so that the distal
end of the tube was located 10 cm from the ground. The
administration speed of the line was graduated at the
highest possible speed (Roller totally opened). The
administration of the formula was timed from the
beginning to finish. The presence or absence of
obstructions was recorded and, if appropriate, the time
at which the stoppage occurred.
The experiment was conducted at 25 C and it was
repeated three times for each formula using each of the
nasogastric tubes described. The average of the three
determinations was the accepted value.

Results
The first phase of the study showed that despite similar
fibre and energy density input, the viscosities of the three
formulas studied were different. The formula with less
viscosity in vitro was Isosource Energy Fibre, followed
by Nutrison Energy Multi Fibre and Jevity Hi Cal,
which proved to be the most viscous (table III).
In the second phase of the study, it was observed that
the administration time of 500 ml of each one of the
formulas was closely related to the viscosity determined in vitro of each of the formulas used, with the
most viscous formula taking the longest to pass
Table III
Viscosity results of enteral nutrition formulas

Determining possible tube obstruction

Possible tube obstruction was determined after the
administration of 1,500 ml of the three enteral nutrition
formulas by gravity. Following agitation of the formula for 30 seconds, it was transferred to a bag of
enteral nutrition, which was hung so that the distal end
of the tube was located 10 cm from the ground. The

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Nutr Hosp. 2009;24(4):492-497

Viscosity (cPs)
Isosource Energy Fibre

26

Nutrison Energy Multi Fibre

52

Jevity Hi Cal

83

P. Casas-Augustench and J. Salas-Salvad

02:30:00

Time of emptying

02:00:00

01:30:00

01:00:00

00:30:00

00:00:00
8FR

9FR

10FR

12FR

ISOSOURCE ENERGY FIBRE

NUTRISON ENERGY MULTI FIBRE
JEVITY HI CAL

through different calibre nasoenteric tubes (table IV,

fig. 1). Moreover, the larger the internal diameter of the
tube, the shorter the emptying time by gravity or free
fall. There was no obstruction of the tube during the
administration of 500 ml of the formulas by free fall
(Roller fully opened) through the different calibre
nasogastric tubes used in this experiment.
In the third phase of the study, which reproduces the
clinical conditions for the routine use of formulas for
enteral nutrition, an obstruction was observed after the
free fall administration of Nutrison Energy Multi
Fibre and Jevity Hi Cal formulas through a 9/18 FR
tube of 1,500 ml/24 h. However, no obstruction was
observed with Isosource Energy Fibre formula when
this volume was administered with the same tube and
conditions, so the residual volume in the bag of enteral
nutrition was practically nil at the end of the infusion.
As can be seen in table 5, the amount of formula that
remained in the bag after the obstruction was higher in
the case of the Jevity Hi Cal formula compared to the
Nutrison Energy Multi Fibre formula.
Discussion
During recent years, the pharmaceutical market has
developed a large number of formulas for enteral nutrition and improved techniques and materials related to
its administration. This development has helped to
improve the nutritional status of patients who need to
be fed artificially and thus, promote their quality of life
both at home and hospital.

Viscosity and flow-rate of three enteral

nutrition formulas

Fig. 1.Graph of time

of administration by
gravity of 500 ml of
each one the formulas
after passing through
different nasoenteric tubes of different calibres
(bars represent the average and standard deviation).

Despite the significant growth in number of formulas and materials, there are still several issues to consider when it comes to managing enteral diets to avoid
possible complications and the possible obstructions of
the tubes.
This work has allowed the study in vitro of the viscosity of three enteral nutrition formulas available in
the European market affects the time of nutritional
administration by free fall. The viscosity determined in
each of the formulas used conditioned the fall times
through tubes with different calibres. Thus, the formulas that were more viscous took more time to flow
gravitationally.
The recommended way of administering to avoid the
dumping effect or diarrhea is 240 to 480 ml of diet over a
period of 20-40 minutes from 4 to 6 times a day1. FollowTable IV
Results of administration time by gravity of 500 ml
of each of the formulas after passing through nasoenteric
tubes with different calibres
Tube

Isosource
Energy
Fibre

Nutrison
Energy
Multi Fibre

Jevity
Hi Cal

8FR

01:08:03 (00:03:27)

01:22:58 (00:05:42)

02:08:00 (00:03:51)

9FR

00:40:47 (00:02:07)

00:48:57 (00:01:52)

01:26:34 (00:09:01)

10FR

00:21:01 (00:01:45)

00:26:48 (00:03:37)

00:42:46 (00:02:22)

12FR

00:13:18 (00:00:51)

00:19:03 (00:01:42)

00:23:47 (00:00:41)

Abbreviations: FR, French.

Time expressed (hh:mm:ss) as mean (standard deviation).

Nutr Hosp. 2009;24(4):492-497

495

Table V
Results of the evaluation of the possibility of tube obstruction after administration by gravity of 1,500 ml of enteral
nutrition formula during 24 hours

Obstruction
Time in which obstruction is produced
Quantity of formula in the bag after 24 h

Isosource Energy
Fibre

Nutrison Energy
Multi Fibre

Jevity Hi Cal

No

Yes

Yes

20:17:17 (01:14:39)

16:43:27 (00:00:42)

14,0 (24,4)

721,7 (216,9)

833,0 (724,9)

ing the results shown in Table 4, this criterion is satisfied

only by the following relationships between tubes and
formulas: a) tube 9FR with Isosource Energy Fibre formula, b) tube 10FR with Isosource Energy Fibre or
Nutrison Energy Multi Fibre formulas, and c) tube 12FR
with Isosource Energy Fibre, Nutrison Energy Multi
Fibre or Jevity Hi Cal formulas. Therefore, it is desirable
not to use other combinations to avoid complications
such as a delay in the diet administration.
The three formulas studied are similar in nutritional
composition, being rich in fibre and energy. These
properties mean these formulas have greater viscosity8
and special care is needed when choosing the most
appropriate type of tube to avoid possible obstructions
or other complications. Although Isosource Energy
Fibre formula is the most caloric and one of the richest
in fibre, it was the one that took the least time to administer by gravity through the various nasoenteric tubes
with different calibre used. Nutrison Energy Multi
Fibre formula has the same fibre content but is more
viscous than Isosource Energy Fibre formula. The
time taken by Nutrison Energy Multi Fibre formula
through the different tubes was higher than for
Isosource Energy Fibre formula. This could be
explained by differences in the viscosity values of
these two products or differences in the source of fibre
used (in the case of Jevity Hi Cal, 75% is insoluble
while in the other two formulas this is approximately
50%). Jevity Hi Cal formula is the most viscous and
quickest to pass through the different tubes used,
despite having a slightly lower content of fibre/100 ml
compared to the other formulas studied.
The degree of viscosity of a formula depends crucially on the density of nutrients incorporated and the
type and quantity of stabilizers used as well as the presence of networks of dispersed particles (especially proteins and polysaccharides) and emulsifiers used to
avoid coalescence, sedimentation and phase separation
of the formula.9,10 Some circumstances of the development process are also essential in viscosity and degree
of dispersion, pH, homogenization and temperature
during the processing, since they alter the possible
interactions between macromolecules present in solution.9,10 This could explain why the three formulas similar in energy density and amount of fibre (two of them
nearly identical) have different viscosities, as we
observed in our study.

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Nutr Hosp. 2009;24(4):492-497

Dietary fibre is essential in maintaining proper bowel

function. Currently it is believed that fibre must be present in preparations for enteral nutrition to manage multiple situations, but the reality is that routine enteral
nutrition often indicated by clinicians does not contain
fibre.7 This is because the formulas rich in fibre can generate problems of: a) administration such as slowing the
infusion speed or obstructing the tube if the calibre that
is very fine, or b) gastrointestinal intolerance. However,
in this experiment there was no tube obstruction during
the administration of 500 ml of formula through the various tubes used, even using formulas which were highly
viscous and rich in fibre. Nevertheless, this does not
mean that these formulas could not produce any obstruction in vivo, since there are other factors that cannot be
taken into account in an in vitro study such as the type of
formula used, contact between the formula and the gastric pH, and the formulas interaction with the medications administered by the same tube. In addition, in our
experiment the roller was totally opened, which is not
habitual in vivo administration conditions.
However, when considering the presence of obstructions in tube 9/18 FR after administration of 1,500
ml/24h of the three enteral nutrition formulas by gravity,
obstructions were observed with Nutrison Energy Multi
Fibre and Jevity Hi Cal formulas. The same phenomenon was not observed for Isosource Energy Fibre formula. Differences in the viscosity and content/type of
fibre of these formulas could explain these divergences.
In conclusion, some of the enteral nutrition formulas
marketed in Europe exceeded the recommended time for
administration by gravity. To avoid delays in the administration of the formulas or other possible complications,
the viscosity of the enteral nutrition formulas should be
included in the labelling of the product. This information
would assist the clinician in making decisions about the
kind of formula to be used for different types and calibres
of tube. In addition, the professional who uses these products should be informed of the type of tubes that should
be used according to the viscosity of the product.
Acknowledgment
We sincerely thank Nestl Healthcare Nutrition
S.A., for their support in carrying out this study. PCC
contributed to the design of the study, acquisition and

P. Casas-Augustench and J. Salas-Salvad

analysis of data, interpretation of results and drafting

the manuscript. JSS contributed to the design and
coordination of the study, interpretation of results and
drafting of the manuscript with intellectual and scientific input. All authors gave their final approval of the
submitted manuscript.

4.

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